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Hartman’s Nursing Assistant CareThe Basics
Hartman Publishing, Inc. with Jetta Fuzy, RN, MS
fifth edition
Special Thanks
A heartfelt thank you goes to our insightful and wonderful reviewers, listed in alphabetical order:
Theresa DeBon, BS, RN Tulsa, OK
Tamie Hodges, BSN, RN Benton, KY
Charles Illian, BSN, RN Orlando, FL
Wendy Marlene Pickard, RN, BS, ONC Round Rock, TX
Alice Sorrell-Thompson, MBA, BSN, RN, PHN Los Angeles, CA
Lori A Spiezio, RN, WCC Telford, PA
We are very appreciative of the many sources who shared their informative photos with us:
• Briggs Corporation
• Detecto
• Dreamstime
• Exergen Corporation
• Harrisburg Area Community College
• Hollister Incorporated
• Invacare Corporation
• Medline Industries
• National Pressure Ulcer Advisory Panel
• North Coast Medical, Inc.
• Nova Medical Products
• RG Medical Diagnostics of Wixom, MI
• Sage Products LLC
• TIDI Products LLC
• Vancare, Inc.
• Welch Allyn
Gender Usage
This textbook uses gender pronouns interchangeably to de-note care team members and residents.
CreditsManaging Editor Susan Alvare Hedman
Designer Kirsten Browne
Cover Illustrator Iveta Vaicule
Photography Matt Pence, Pat Berrett, Art Clifton, and Dick Ruddy
Proofreaders Sara Alexander, Sapna Desai, and Joanna Owusu
Editorial Assistant Angela Storey
Sales/Marketing Deborah Rinker, Kendra Robertson, Erika Walker, Belinda Midyette, and Carol Castillo
Customer Service Fran Desmond, Thomas Noble, Col Foley, Brian Fejer, and Henry Bullis
Information Technology Eliza Martin
Warehouse Coordinator Chris Midyette
Copyright Information
© 2019 by Hartman Publishing, Inc. 1313 Iron Ave SW Albuquerque, NM 87102 (505) 291-1274 web: hartmanonline.com email: [email protected] Twitter: @HartmanPub
All rights reserved. No part of this book may be reproduced, in any form or by any means, without permission in writing from the publisher.
ISBN 978-1-60425-100-5
PRINTED IN CANADA
Notice to Readers
Though the guidelines and procedures contained in this text are based on consultations with healthcare profession-als, they should not be considered absolute recommenda-tions. The instructor and readers should follow employer, local, state, and federal guidelines concerning healthcare practices. These guidelines change, and it is the reader’s re-sponsibility to be aware of these changes and of the policies and procedures of his or her healthcare facility.
The publisher, authors, editors, and reviewers cannot ac-cept any responsibility for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with re-spect to the contents of the book. The publisher does not warrant or guarantee any of the products described herein or perform any analysis in connection with any of the prod-uct information contained herein.
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1 The Nursing Assistant in Long-Term Care1. Compare long-term care to other healthcare settings 1
2. Describe a typical long-term care facility 2
3. Explain Medicare and Medicaid 3
4. Describe the nursing assistant’s role 4
5. Describe the care team and the chain of command 5
6. Define policies, procedures, and professionalism 8
7. List examples of legal and ethical behavior and explain Residents’ Rights 10
8. Explain legal aspects of the resident’s medical record 18
9. Explain the Minimum Data Set (MDS) 20
10. Discuss incident reports 20
2 Foundations of Resident Care1. Understand the importance of verbal and written communications 21
2. Describe barriers to communication 24
3. List guidelines for communicating with residents with special needs 26
4. Identify ways to promote safety and handle non-medical emergencies 31
5. Demonstrate how to recognize and respond to medical emergencies 37
6. Describe and demonstrate infection prevention and control practices 45
3 Understanding Residents1. Identify basic human needs 60
2. Define holistic care 62
3. Explain why promoting independence and self-care is important 62
4. Identify ways to accommodate cultural differences 63
5. Describe the need for activity 64
6. Discuss family roles and their significance in health care 65
7. Describe the stages of human growth and development 66
8. Discuss developmental disabilities 69
9. Describe some types of mental health disorders 70
10. Explain how to care for residents who are dying 72
11. Define the goals of a hospice program 76
4 Body Systems and Related Conditions1. Describe the integumentary system 79
2. Describe the musculoskeletal system and related conditions 80
3. Describe the nervous system and related conditions 84
4. Describe the circulatory system and related conditions 90
5. Describe the respiratory system and related conditions 94
6. Describe the urinary system and related conditions 96
7. Describe the gastrointestinal system and related conditions 98
8. Describe the endocrine system and related conditions 102
9. Describe the reproductive system and related conditions 104
10. Describe the immune and lymphatic systems and related conditions 106
5 Confusion, Dementia, and Alzheimer’s Disease1. Discuss confusion and delirium 111
2. Describe dementia and discuss Alzheimer’s disease 112
3. List strategies for better communication with residents with Alzheimer’s disease 114
4. List and describe interventions for problems with common activities of daily living (ADLs) 116
5. List and describe interventions for common difficult behaviors related to Alzheimer’s disease 118
6. Describe creative therapies for residents with Alzheimer’s disease 122
Learning Objective PagePage
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Contents
6 Personal Care Skills1. Explain personal care of residents 124
2. Identify guidelines for providing skin care and preventing pressure injuries 125
3. Describe guidelines for assisting with bathing 129
4. Describe guidelines for assisting with grooming 138
5. List guidelines for assisting with dressing 143
6. Identify guidelines for proper oral hygiene 147
7. Explain guidelines for assisting with toileting 152
8. Explain guidelines for safely positioning and moving residents 157
7 Basic Nursing Skills1. Explain admission, transfer, and discharge of a resident 169
2. Explain the importance of monitoring vital signs 173
3. Explain how to measure weight and height 186
4. Explain restraints and how to promote a restraint-free environment 188
5. Define f luid balance and explain intake and output (I&O) 190
6. Explain care guidelines for urinary catheters, oxygen therapy, and IV therapy 196
7. Discuss a resident’s unit and related care 200
8. Explain the importance of sleep and perform proper bedmaking 202
9. Discuss dressings and bandages 207
8 Nutrition and Hydration1. Identify the six basic nutrients and explain MyPlate 209
2. Describe factors that influence food preferences 213
3. Explain special diets 213
4. Describe how to assist residents in maintaining fluid balance 216
5. List ways to identify and prevent unintended weight loss 218
6. Identify ways to promote appetites at mealtime 219
7. Demonstrate how to assist with eating 219
8. Identify signs and symptoms of swallowing problems 222
9. Describe how to assist residents with special needs 225
9 Rehabilitation and Restorative Care1. Discuss rehabilitation and restorative care 227
2. Describe the importance of promoting independence and list ways exercise improves health 228
3. Discuss ambulation and describe assistive devices and equipment 229
4. Explain guidelines for maintaining proper body alignment 232
5. Describe care guidelines for prosthetic devices 233
6. Describe how to assist with range of motion exercises 234
7. List guidelines for assisting with bladder and bowel retraining 239
10 Caring for Yourself1. Describe how to find a job 241
2. Describe a standard job description and explain how to manage time and assignments 243
3. Discuss how to manage and resolve conflict 244
4. Describe employee evaluations and discuss appropriate responses to feedback 245
5. Discuss certification and explain the state’s registry 246
6. Describe continuing education 246
7. Explain ways to manage stress 247
Abbreviations 250
Glossary 251
Index 262
Learning Objective Learning ObjectivePage Page
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Procedure ProcedurePage Page
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ProceduresPerforming abdominal thrusts for the conscious person 38
Responding to shock 39
Responding to a myocardial infarction 40
Controlling bleeding 40
Treating burns 41
Responding to fainting 42
Responding to seizures 43
Responding to vomiting 45
Washing hands (hand hygiene) 49
Putting on (donning) and removing (doffing) gown 51
Putting on (donning) mask and goggles 52
Putting on (donning) gloves 53
Removing (doffing) gloves 53
Caring for an ostomy 101
Giving a complete bed bath 129
Giving a back rub 133
Shampooing hair in bed 134
Giving a shower or a tub bath 136
Providing fingernail care 138
Providing foot care 139
Combing or brushing hair 141
Shaving a resident 142
Dressing a resident 144
Applying knee-high elastic stockings 146
Providing oral care 147
Providing oral care for the unconscious resident 149
Flossing teeth 150
Cleaning and storing dentures 151
Assisting a resident with the use of a bedpan 153
Assisting a male resident with a urinal 154
Assisting a resident to use a portable commode or toilet 156
Moving a resident up in bed 158
Moving a resident to the side of the bed 158
Positioning a resident on his side 159
Logrolling a resident 161
Assisting resident to sit up on side of bed: dangling 162
Transferring a resident from bed to wheelchair 165
Transferring a resident using a mechanical lift 167
Admitting a resident 170
Transferring a resident 171
Discharging a resident 172
Measuring and recording an oral temperature 175
Measuring and recording a rectal temperature 177
Measuring and recording a tympanic temperature 178
Measuring and recording an axillary temperature 179
Counting and recording radial pulse and counting and recording respirations 181
Measuring and recording blood pressure (one-step method) 183
Measuring and recording weight of an ambulatory resident 186
Measuring and recording height of an ambulatory resident 187
Measuring and recording urinary output 191
Collecting a routine urine specimen 192
Collecting a clean-catch (mid-stream) urine specimen 194
Collecting a stool specimen 195
Providing catheter care 196
Emptying the catheter drainage bag 198
Making an occupied bed 203
Making an unoccupied bed 206
Changing a dry dressing using non-sterile technique 207
Serving fresh water 217
Feeding a resident 221
Assisting a resident to ambulate 229
Assisting with ambulation for a resident using a cane, walker, or crutches 231
Assisting with passive range of motion exercises 235
Understanding how this book is organized and what its special features are will help you make the most of this resource!
Using a Harman Texbok
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Residents’ Rights
Abuse and Alzheimer’s DiseasePeople with Alzheimer’s disease may be at a higher risk for abuse.
Making an occupied bed
Guidelines: Preventing Falls
We have assigned each chapter its own colored tab. Each colored tab contains the chapter number and title, and it is on the side of every page.
1. List examples of legal and ethical behavior
bloodborne pathogens
Everything in this book, the student workbook, and the instructor’s teaching material is organized around learning objectives. A learning objective is a very specific piece of knowledge or a very specific skill. After reading the text, if you can do what the learning objective says, you know you have mastered the material.
Bold key terms are located throughout the text, followed by their definitions. They are also listed in the glossary at the back of this book.
All care procedures are highlighted by the same black bar for easy recognition.
This icon indicates that Hartman Publishing offers a corresponding video for this skill.
Guidelines and Observing and Reporting lists are colored green for easy reference.
These boxes teach important information about how to support and promote Residents’ Rights and person-centered care.
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Beginning Steps
Identify yourself by name. Identify the resident by name.
A resident’s room is his home. Residents have a legal right to pri-vacy. Before any procedure, knock and wait for permission to enter the resident’s room. Upon entering his room, identify yourself and state your title. Residents have the right to know who is providing their care. Identify and greet the resident. This shows courtesy and respect. It also establishes correct identification. This pre-vents care from being performed on the wrong person.
Wash your hands. Handwashing provides for infection prevention. Nothing fights infection in facilities like performing consistent, proper hand hy-giene. Handwashing may need to be done more than once during a procedure. Practice Standard Precautions with every resident.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Residents have a legal right to know exactly what care you will pro-vide. It promotes understanding, cooperation, and independence. Residents are able to do more for themselves if they know what needs to happen.
Provide for the resident’s privacy with a curtain, screen, or door.
Doing this maintains the resident's right to privacy and dignity. Providing for privacy in a facility is not simply a courtesy; it is a legal right.
Adjust the bed to a safe level, usually waist high. Lock the bed wheels.
Locking the bed wheels is an important safety measure. It ensures that the bed will not move as you are performing care. Raising the bed helps you to remember to use proper body mechanics. This prevents injury to you and to residents.
Beginning and ending steps in care procedures
For most care procedures, these steps should be performed. Understanding why they are important will help you remember to perform each step every time care is provided.
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Ending Steps
Return bed to lowest position. Remove privacy measures.
Lowering the bed provides for the resident’s safety. Remove extra privacy measures added during the procedure. This includes any-thing you may have draped over and around the resident, as well as privacy screens.
Place call light within resident’s reach.
A call light allows the resident to communicate with staff as nec-essary. It must always be left within the resident’s reach. You must respond to call lights promptly.
Wash your hands. Handwashing is the most important thing you can do to prevent the spread of infection.
Report any changes in resident to the nurse. Document procedure using facility guidelines.
You will often be the person who spends the most time with a resident, so you are in the best position to note any changes in a resident’s condition. Every time you provide care, observe the resi-dent’s physical and mental capabilities, as well as the condition of his or her body. For example, a change in a resident’s ability to dress himself may signal a greater problem. After you have fin-ished giving care, document the care using facility guidelines. Do not record care before it is given. If you do not document the care you gave, legally it did not happen.
In addition to the beginning and end-ing steps listed above, remember to follow infection prevention guide-lines. Even if a procedure in this book does not tell you to wear gloves or other PPE, there may be times when it is appropriate.
A few procedures in this book men-tion positioning side rails on beds, but most references to side rails have been omitted. This is due to the decline in their use because of risk of injury. Follow your facility’s policies regarding side rails.
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1. Compare long-term care to other healthcare settings
Welcome to the world of health care! Health care happens in many places. Nursing assistants work in many of these settings. In each setting similar tasks will be performed. However, each setting is also unique.
This textbook will focus on long-term care. Long-term care (LTC) is given in long-term care facilities for people who need 24-hour skilled care. Skilled care is medically necessary care given by a skilled nurse or therapist; it is avail-able 24 hours a day. It is ordered by a doctor and involves a treatment plan. This type of care is given to people who need a high level of care for ongoing conditions. The term nursing homes was once widely used to refer to these facilities. Now they are often known as long-term care facilities, skilled nursing facilities, rehabilitation centers, or extended care facilities.
People who live in long-term care facilities may be disabled. They are often elderly, but younger adults sometimes require long-term care, too. They may arrive from hospitals or other health-care settings. Their length of stay (the number of days a person stays in a care facility) may be short, such as a few days or months, or longer than six months. Some of these people will have a terminal illness. This means that the illness will eventually cause death. Other people may recover and return to their homes or to other care facilities or situations.
The Nursing Assistant in Long-Term Care
Most people who live in long-term care facilities have chronic conditions. This means the condi-tion lasts a long period of time, even a lifetime. Chronic conditions include physical disabilities, heart disease, and dementia. (Chapters 4 and 5 have more information about these disorders and diseases.) People who live in these facilities are usually referred to as residents because the facility is where they reside or live. These places are their homes for the duration of their stay (Fig. 1-1).
Fig. 1-1. People who live in long-term care facilities are called residents because the facility is where they reside for the duration of their stay.
People who need long-term care will have dif-ferent diagnoses, or medical conditions de-termined by a doctor. The stages of illness or disease affect how sick people are and how much care they will need. The tasks nursing as-sistants perform will also vary. This is due to the fact that each resident has different symptoms, abilities, and needs.
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Other healthcare settings include the following:
Home health care, or home care, is provided in a person’s home (Fig. 1-2). This type of care is generally given to people who are older and are chronically ill but who are able to and wish to remain at home. Home care may also be needed when a person is weak after a recent hospital stay. Home care includes many of the services offered in other settings.
Fig. 1-2. Home care is performed in a person’s home.
Assisted living facilities are residences for people who need some help with daily tasks, such as showering, eating, and dressing. Help with medications may also be given. People who live in these facilities do not need 24-hour skilled care. Assisted living facilities allow more independent living in a homelike environment. An assisted living facility may be attached to a long-term care facility, or it may stand alone.
Adult day services are for people who need some help and supervision during certain hours, but who do not live in the facility where care is provided. Generally, adult day services are for people who need some help but are not seriously ill or disabled. Adult day services can also pro-vide a break for spouses, family members, and friends.
Acute care is 24-hour skilled care given in hos-pitals and ambulatory surgical centers. It is for people who require short-term, immediate care for illnesses or injuries (Fig. 1-3). People are also admitted for short stays for surgery.
Fig. 1-3. Acute care is performed in hospitals for illnesses or injuries that require immediate care.
Subacute care is care given in hospitals or long-term care facilities. It is used for people who need less care than for an acute (sudden onset, short-term) illness, but more care than for a chronic (long-term) illness. Treatment usually ends when the condition has stabilized or after the set time for treatment has been completed. The cost is usually less than for acute care but more than for long-term care.
Outpatient care is usually given to people who have had treatments, procedures, or surgeries and need short-term skilled care. They do not require an overnight stay in a hospital or other care facility.
Rehabilitation is care given by specialists. Phys-ical, occupational, and speech therapists help restore or improve function after an illness or in-jury. Information about rehabilitation is located in Chapter 9.
Hospice care is given in facilities or homes for people who have about six months or less to live. Hospice workers give physical and emotional care and comfort until a person dies. They also support families during this process. More in-formation may be found in Chapter 3.
2. Describe a typical long-term care facility
Long-term care facilities are businesses that pro-vide skilled nursing care 24 hours a day. These facilities may offer assisted living housing, de-mentia care, or subacute care. Some facilities
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offer specialized care. Others care for all types of residents. The typical long-term care facility offers personal care for all residents and focused care for residents with special needs. Personal care includes bathing; skin, nail, and hair care; mouth care; and assistance with walking, eating and drinking, dressing, transferring, and elimi-nation. All of these daily personal care tasks are called activities of daily living, or ADLs. Other common services offered at these facilities in-clude the following:
• Physical, occupational, and speech therapy
• Wound care
• Care of different types of tubes, such as cath-eters (thin tubes inserted into the body to drain fluids or inject fluids)
• Nutrition therapy
• Management of chronic diseases, such as Alzheimer’s disease, acquired immunodefi-ciency syndrome (AIDS), diabetes, chronic obstructive pulmonary disease (COPD), can-cer, and congestive heart failure (CHF)
When specialized care is offered at long-term care facilities, the employees must have special training. Residents with similar needs may be placed in units together. Nonprofit companies or for-profit companies can own long-term care facilities.
Residents’ Rights
Culture Change and Person-Centered CareMany long-term care facilities promote meaning-ful environments with individualized approaches to care. Culture change is a term given to the process of transforming services for elders so that they are based on the values and practices of the person re-ceiving care. Culture change involves respecting both elders and those working with them. Core values are promoting choice, dignity, respect, self-determina-tion, and purposeful living. To honor culture change, care settings may need to change their organization, practices, physical environments, and relationships. Person-centered care emphasizes the individuality of the person who needs care, and recognizes and
develops his or her capabilities. Person-centered care revolves around the resident and promotes his or her individual preferences, choices, dignity, and interests. Each person’s background, culture, language, beliefs, and traditions are respected. Im-proving each resident’s quality of life is an important goal. Giving person-centered care will be an ongoing focus throughout this textbook.
3. Explain Medicare and Medicaid
The Centers for Medicare & Medicaid Services (CMS, cms.gov) is a federal agency within the US Department of Health and Human Services. CMS runs two national healthcare programs—Medicare and Medicaid. They both help pay for health care and health insurance for millions of Americans. CMS has many other responsibili-ties as well.
Medicare (medicare.gov) is a federal health in-surance program that was established in 1965 for people aged 65 or older. It also covers people of any age with permanent kidney failure or cer-tain disabilities. Medicare has four parts. Part A helps pay for care in a hospital or skilled nursing facility or for care from a home health agency or hospice. Part B helps pay for doctor services and other medical services and equipment. Part C allows private health insurance companies to provide Medicare benefits. Part D helps pay for medications prescribed for treatment. Medicare will only pay for care it determines to be medi-cally necessary.
Medicaid (medicaid.gov) is a medical assistance program for people who have a low income, as well as for people with disabilities. It is funded by both the federal government and each state. Eligibility is determined by income and special circumstances. People must qualify for this program.
Medicare and Medicaid pay long-term care facili-ties a fixed amount for services. This amount is based on the resident’s needs upon admission and throughout his stay at the facility.
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4. Describe the nursing assistant’s role
A nursing assistant can have many different titles. Nurse aide, certified nurse aide, patient care technician, and certified nursing assistant are some examples. The title given varies by state requirements. This textbook uses the term nursing assistant.
A nursing assistant (NA) performs assigned nursing tasks, such as taking a resident’s tem-perature. A nursing assistant also provides personal care, such as bathing residents and helping with hair care. Promoting independence and self-care are other very important tasks that a nursing assistant does. Common nursing as-sistant duties include the following:
• Bathing residents
• Helping residents with elimination needs
• Assisting with range of motion exercises and ambulation (walking)
• Transferring residents from a bed to a chair or wheelchair
• Measuring vital signs (temperature, pulse rate, respiratory rate, and blood pressure)
• Assisting with meals (Fig. 1-4)
Fig. 1-4. Helping residents eat and drink is an important part of an NA’s job.
• Helping residents dress and undress
• Giving back rubs
• Helping with mouth care
• Making and changing beds
• Keeping residents’ living areas neat and clean
• Caring for supplies and equipment
Nursing assistants are not allowed to insert or re-move tubes, give tube feedings, or change sterile dressings. Some states allow nursing assistants to give medications if they have completed an ad-ditional, specialized course for medications and meet the requirements of the individual facility.
Nursing assistants spend more time with resi-dents than other care team members. They act as the “eyes and ears” of the team. Observing changes in a resident’s condition and reporting them is a very important duty of the NA. Resi-dents’ care can be revised or updated as condi-tions change. Another duty of the NA is noting important information about the resident (Fig. 1-5). This is called charting, or documenting.
Fig. 1-5. Observing carefully and reporting accurately are some of the NA’s most important duties.
Nursing assistants are part of a team of health professionals. The team includes doctors, nurses, social workers, therapists, dietitians, and special-ists. The resident and resident’s family are part of the team too. Everyone, including the resident, works closely together to meet goals. Goals in-clude helping residents to recover from illnesses and to do as much as possible for themselves.
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Residents’ Rights
Responsibility for ResidentsAll residents are the responsibility of each nursing assistant. An NA will receive assignments to perform tasks, care, and other duties for specific residents. If he sees a resident who needs help, even if the resi-dent is not on his assignment sheet, the NA should provide the needed care.
5. Describe the care team and the chain of command
Residents will have different needs and prob-lems. Healthcare professionals with a wide range of education and experience will help care for them. This group is known as the care team. Members of the care team include the following:
Nursing Assistant (NA) or Certified Nursing As-sistant (CNA): The nursing assistant performs assigned tasks, such as taking vital signs. The NA also provides or assists with personal care, such as bathing residents and helping with elimination needs. Nursing assistants must have at least 75 hours of training, and in many states, training exceeds 100 hours.
Registered Nurse (RN): In a long-term care fa-cility, a registered nurse coordinates, manages, and provides skilled nursing care. This includes giving special treatments and medications as prescribed by a doctor. A registered nurse also assigns tasks and supervises daily care of resi-dents by nursing assistants. A registered nurse is a licensed professional who has graduated from a two- to four-year (associate’s or bach-elor’s) nursing program. RNs have diplomas or college degrees. They have passed a national licensure examination. Registered nurses may have additional academic degrees or education in specialty areas.
Licensed Practical Nurse (LPN) or Licensed Vo-cational Nurse (LVN): A licensed practical nurse or licensed vocational nurse gives medications and treatments. An LPN or LVN is a licensed professional who has completed one to two years
of education and has passed a national licensure examination.
Physician or Doctor (MD [medical doctor] or DO [doctor of osteopathy]): A doctor diagnoses disease or disability and prescribes treatment (Fig. 1-6). Doctors have graduated from four-year medical schools, which they attend after receiv-ing bachelor’s degrees. Many doctors also attend specialized training programs after medical school.
Fig. 1-6. A doctor makes a diagnosis and prescribes treatment.
Physical Therapist (PT or DPT): A physical thera-pist evaluates a person and develops a treatment plan. Goals are to increase movement, improve circulation, promote healing, reduce pain, pre-vent disability, and regain or maintain mobility (Fig. 1-7). A PT gives therapy in the form of heat, cold, massage, ultrasound, electrical stimulation, and exercise to muscles, bones, and joints. A physical therapist has graduated from a three-year doctoral degree program (doctor of physical therapy, or DPT) after receiving an undergradu-ate degree. PTs have to pass a national licensure examination before they can practice.
Occupational Therapist (OT): An occupational therapist helps residents learn to adapt to dis-abilities. An OT may help train residents to per-form activities of daily living, such as bathing, dressing, and eating. This often involves the use of equipment called assistive or adaptive de-vices. The OT evaluates the resident’s needs and plans a treatment program. Occupational
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therapists have earned a master’s degree. OTs must pass a national licensure examination be-fore they can practice.
Fig. 1-7. A physical therapist helps exercise muscles, bones, and joints to improve strength or restore abilities.
Speech-Language Pathologist (SLP): A speech-lan-guage pathologist, or speech therapist, identifies communication disorders, addresses factors in-volved in recovery, and develops a plan of care to meet goals. An SLP teaches exercises to help the resident improve or overcome speech problems. An SLP also evaluates a person’s ability to swal-low food and drink. Speech-language pathologists have earned a master’s degree in speech-language pathology and are licensed or certified to work.
Registered Dietitian (RD or RDN): A registered dietitian evaluates a resident’s nutritional status and develops a treatment plan to improve health and manage illness. An RD creates a diet to meet a resident’s special needs. She may super-vise the preparation and service of food and edu-cate people about nutrition. Registered dietitians have completed a bachelor’s degree. They may also have completed postgraduate work. Most states require that RDs be licensed or certified.
Medical Social Worker (MSW): A medical social worker determines residents’ needs and helps get them support services, such as counseling and financial assistance. He may help residents obtain clothing and personal items if the family is not involved or does not visit often. A medical
social worker may book appointments and trans-portation. MSWs have usually earned a master’s degree in social work.
Activities Director: The activities director plans activities for residents to help them socialize and stay active. These activities are meant to improve and maintain residents’ well-being and to prevent further complications from illness or disability. Games, performances, and arts and crafts are some types of activities that the activities director may plan or lead. An activities director has usu-ally earned a bachelor’s degree; however, she may have an associate’s degree or qualifying work experience. An activities director may be called a recreational therapist or recreation worker, depend-ing upon education and experience.
Resident and Resident’s Family: The resident is an important member of the care team. Pro-viding person-centered care means placing the resident’s well-being first, and giving her the right to make decisions and choices about her own care. The resident helps plan care, and the resident’s family may also be involved in these decisions. The family is a great source of infor-mation. They know the resident’s personal pref-erences, history, diet, habits, and routines.
Residents’ Rights
Resident as Member of Care TeamAll members of the care team should focus on the resident. The team revolves around the resident and his or her condition, treatment, and progress. With-out the resident, there is no care team.
A nursing assistant carries out instructions given to her by a nurse. The nurse is acting on the instructions of a doctor or other member of the care team. This is called the chain of com-mand. It describes the line of authority and helps to make sure that residents get proper health care. The chain of command also protects employees and employers from liability. Liabil-ity is a legal term. It means that someone can be held responsible for harming someone else. For example, imagine that a task an NA does for a
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resident harms that resident. However, the task was in the care plan and was done according to policy and procedure. In this case, the NA may not be liable, or responsible, for hurting the resi-dent. However, if the NA does something not in the care plan that harms a resident, she could be held responsible. That is why it is important for the team to follow instructions and for the facil-ity to have a chain of command (Fig. 1-8).
Administrator: manages non-medical aspects of the facility, administers nances, and coordinates policy in consultation with medical professionals
Medical Director (MD): reviews and consults on medical aspects of care, coordinating with attending physicians and nursing sta� and encouraging quality care
Director of Nursing (DON): manages the nursing sta� at a facility
Assistant Director of Nursing (ADON): assists the DON with the management of nursing sta�
Sta� Development Coordinator: directs the training of employees at a facility
Minimum Data Set (MDS) Coordina-tor/Resident Assessment Coordina-tor: manages the assessment of resident needs and delivery of required care in a long-term care facility (usually a specially trained nurse)
Nursing Supervisor: supervises and supports nursing sta� of the entire facility or multiple nursing units, assisting with resident care as needed
Charge Nurse: supervises and supports nursing sta� of a particular unit and treats a limited number of residents
Sta� Nurses (RNs, LPNs/LVNs): provide nursing care as prescribed by a physician
Nursing Assistants (NAs, CNAs): perform assigned nursing tasks, assist with routine personal care, and observe and report any changes in residents’ conditions and abilities
Other Services
Physical Therapist (PT): administers therapy to increase movement, promote healing, reduce pain, and prevent disability
Occupational Therapist (OT): helps residents learn to adapt to disabilities and trains them to perform ADLs
Speech-Language Pathologist (SLP): identies communica-tion disorders and swallowing problems and develops a plan of care
Fig. 1-8. The chain of command describes the line of author-ity and helps ensure that the resident receives proper care.
Nursing assistants must understand what they can and cannot do. This is so that they do not harm residents or involve themselves or their employers in lawsuits. Some states certify that nursing assistants are qualified to work. How-ever, nursing assistants are not licensed health-care providers. Everything they do in their job is assigned to them by a licensed healthcare profes-sional. That is why these professionals will show great interest in what NAs do and how they do it.
Every state grants the right to practice various jobs in health care through licensure. Examples include a license to practice nursing, medicine, or physical therapy. Each member of the care team works within his or her scope of practice. A scope of practice defines the tasks that healthcare providers are legally allowed to do as permitted by state or federal law. Laws and regulations about what NAs can and cannot do vary from state to state. It is important that NAs know which tasks are outside their scope of practice and not perform them.
The care plan is individualized for each resi-dent. It is developed to help achieve the goals of care. The care plan lists the tasks that team members, including NAs, must perform. It states how often these tasks should be per-formed and how they should be carried out.
Care planning should involve input from the resident and/or the family, as well as from health professionals. Person-centered care places special emphasis on the importance of the resi-dent’s input.
The care plan is a guide to help the resident be as healthy as possible. It must be followed carefully. It is critical that NAs make observa-tions and report them to the nurse. Even simple observations can be very important. The infor-mation that NAs collect and the changes they observe help determine how care plans may need to change. NAs spend so much time with residents; they are likely to have valuable infor-mation that will help in care planning.
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6. Def ine policies, procedures, and professionalism
All facilities have manuals outlining their poli-cies and procedures. A policy is a course of ac-tion that should be taken every time a certain situation occurs. For example, a very basic policy is that healthcare information must remain confidential. A procedure is a method, or way, of doing something. For example, a facility will have a procedure for reporting information about residents. The procedure explains what form to complete, when and how often to com-plete it, and to whom it is given. New employees will be told where to find a list of policies and procedures that all staff are expected to follow. Common policies at long-term care facilities in-clude the following:
• All resident information must remain con-fidential. This is not only a facility rule; it is also the law. More information about con-fidentiality, including the Health Insurance Portability and Accountability Act (HIPAA), can be found later in the chapter.
• The care plan must always be followed. Tasks not listed in the care plan or approved by the nurse should not be performed.
• Nursing assistants should not do tasks that are not included in their job description.
• Nursing assistants must report impor-tant events or changes in residents to a nurse.
• Nursing assistants should not discuss their personal problems with residents or resi-dents’ families.
• Nursing assistants should not take money or gifts from residents or their families.
• Nursing assistants must be on time for work and must be dependable.
Employers will have policies and procedures for every resident care situation. These have been developed to give quality care and protect resi-
dent safety. Procedures may seem long and com-plicated, but each step is important. NAs must become familiar with and always follow policies and procedures.
Professional means having to do with work or a job. Personal refers to life outside a job, such as family, friends, and home life. Professional-ism is behaving properly when on the job. It includes dressing appropriately and speaking well. It also includes being on time, completing tasks, and reporting to the nurse. For an NA, professionalism means following the care plan, making careful observations, and reporting ac-curately. Following policies and procedures is an important part of professionalism. Residents, coworkers, and supervisors respect employees who behave professionally. Professionalism helps people keep their jobs. It may also help them earn promotions and raises.
A professional relationship with residents in-cludes the following:
• Providing person-centered care
• Keeping a positive attitude
• Doing only the assigned tasks that are in the care plan and that the NA is trained to do
• Keeping all residents’ information confidential
• Always being polite and cheerful (Fig. 1-9)
• Not discussing personal problems
Fig. 1-9. Nursing assistants are expected to always be po-lite and cheerful.
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• Not using personal phones in residents’ rooms or in any resident care area
• Not using profanity, even if a resident does
• Listening to the resident
• Calling a resident Mr., Mrs., Ms., or Miss, and his or her last name, or by the name he or she prefers; terms such as sweetie, honey, dearie, etc., are disrespectful and should not be used
• Never giving or accepting gifts
• Always explaining care before providing it
• Following practices, such as handwashing, to protect oneself and residents
A professional relationship with employers in-cludes the following:
• Completing tasks efficiently
• Always following all policies and procedures
• Documenting and reporting carefully and correctly
• Reporting problems with residents or tasks
• Reporting anything that keeps an NA from completing duties
• Asking questions when the NA does not know or understand something
• Taking directions or feedback without be-coming upset
• Being clean and neatly dressed and groomed
• Always being on time
• Telling the employer if the NA cannot report for work
• Following the chain of command
• Participating in education programs
• Being a positive role model for the facility
Nursing assistants must be:
• Compassionate: Being compassionate is being caring, concerned, empathetic, and understanding. Demonstrating empathy
means identifying with the feelings of oth-ers. People who are compassionate under-stand others’ problems. They care about them. Compassionate people are also sympa-thetic. Showing sympathy means sharing in the feelings and difficulties of others.
• Honest: An honest person tells the truth and can be trusted. Residents need to feel that they can trust those who care for them. The care team depends on honesty in planning care. Employers count on truthful records of care given and observations made.
• Tactful: Being tactful means showing sensi-tivity and having a sense of what is appropri-ate when dealing with others.
• Conscientious: People who are conscien-tious try to do their best. They are guided by a sense of right and wrong. They are alert, observant, accurate, and responsible. Giving conscientious care means making accurate observations and reports, following the care plan, and taking responsibility for one’s actions (Fig. 1-10).
Fig. 1-10. Nursing assistants must be conscientious about documenting observations and procedures.
• Dependable: NAs must be able to make and keep commitments. They must be at work on time. They must skillfully do tasks, avoid absences, and help their peers when needed.
• Patient: People who are patient do not lose their temper easily. They do not act irritated or complain when things are hard. Residents are often elderly and may be sick or in pain.
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They may take a long time to do things. They may become upset. NAs must not rush residents or act annoyed.
• Respectful: Being respectful means valuing other people’s individuality. This includes their age, religion, culture, feelings, prac-tices, and beliefs. People who are respectful treat others politely and kindly.
• Unprejudiced: NAs work with people from many different backgrounds. They must give each resident the same quality care regard-less of age, gender, sexual orientation, reli-gion, race, ethnicity, or condition.
• Tolerant: Being tolerant means respecting others’ beliefs and practices and not judg-ing them. NAs may not like or agree with things that residents or their families do or have done. However, their job is to care for each resident as assigned, not to judge him or her. NAs should put aside their opinions. They should see each resident as an indi-vidual who needs their care.
7. List examples of legal and ethical behavior and explain Residents’ Rights
Ethics and laws guide behavior. Ethics are the knowledge of right and wrong. An ethical per-son has a sense of duty toward others. He tries to do what is right. Laws are rules set by the government to help people live peacefully to-gether and to ensure order and safety. Ethics and laws are very important in health care. They pro-tect people receiving care and guide those giving care. NAs and all care team members should be guided by a code of ethics. They must know the laws that apply to their jobs.
Guidelines: Legal and Ethical Behavior
G Be honest at all times.
G Protect residents’ privacy and confidentiality. Do not discuss their cases except with other members of the care team.
G Keep staff information confidential.
G Report abuse or suspected abuse of resi-dents. Help residents report abuse if they wish to make a complaint of abuse.
G Follow the care plan and assignments. If you make a mistake, report it promptly.
G Do not perform any tasks outside your scope of practice.
G Report all resident observations and inci-dents to the nurse.
G Document accurately and promptly.
G Follow rules about safety and infection pre-vention (see Chapter 2).
G Do not accept gifts or tips (Fig. 1-11).
G Do not get personally or sexually involved with residents or their family members or friends.
Fig. 1-11. Nursing assistants should not accept money or gifts because it is unprofessional and may lead to conflict.
The Omnibus Budget Reconciliation Act (OBRA) was passed in 1987. It has been up-dated several times since. OBRA was passed in response to reports of poor care and abuse in long-term care facilities. Congress decided to set minimum standards of care, which included standardized training of nursing assistants.
OBRA requires that the Nurse Aide Training and Competency Evaluation Program (NATCEP) set minimum standards for nursing assistant training. NAs must complete at least 75 hours of training that covers topics like communication,
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preventing infections, safety and emergency pro-cedures, and promoting residents’ independence and legal rights. Training must also include basic nursing skills, such as how to measure vital signs. NAs must also know how to respond to mental health and social services needs, re-habilitative needs, and how to care for residents who are cognitively impaired.
OBRA requires that NAs pass a competency evaluation (testing program) before they can be employed. NAs must also attend regular in-ser-vice education (a minimum of 12 hours per year) to keep their skills updated.
OBRA also requires that states keep a current list of nursing assistants in a state registry. In addition, OBRA identifies standards that in-structors must meet in order to train nursing assistants. OBRA sets guidelines for minimum staff requirements and specific services that long-term care facilities must provide.
The resident assessment requirements are an-other important part of OBRA. OBRA requires that complete assessments be done on every resident. The assessment forms are the same for every facility.
OBRA made major changes in the survey pro-cess. Surveys are inspections to help make sure that long-term care facilities follow state and fed-eral regulations. Surveys are done periodically by the state agency that licenses facilities. They may be done more often if a facility has been cited for problems. To cite means to find a problem through a survey. Inspections may be done less often if the facility has a good record. Inspection teams include a variety of trained healthcare pro-fessionals. The results from surveys are available to the public and posted in the facility.
OBRA also identifies important rights for resi-dents in long-term care facilities. Residents’ Rights specify how residents must be treated while living in a facility. They are an ethical code of conduct for healthcare workers. Facility staff give residents a list of these rights and review
each right with them. In 2016, the Centers for Medicare and Medicaid Services (CMS) finalized a rule to improve the care and safety of resi-dents in long-term care facilities. It was the first comprehensive update since 1991. It includes strengthening the rights of residents who live in long-term care facilities. NAs must be familiar with these legal rights. Residents’ Rights include the following:
Quality of life: Residents have the right to the best care available. Dignity, choice, and indepen-dence are important parts of quality of life. The facility must give equal access to quality care regardless of a resident’s condition, diagnosis, or payment source.
Services and activities to maintain a high level of wellness: Residents must receive the correct care. Healthcare professionals at facilities must develop a care plan for residents, and their care should keep them as healthy as possible. A baseline care plan for residents, which includes instructions for providing person-centered care, must be developed within 48 hours of admis-sion. Residents’ health should not decline as a direct result of the care given at the facility.
The right to be fully informed about rights and services: Residents must be told what services are available. They must be told the fee for each service. They must be informed of charges both orally and in writing. Residents must be given a written copy of their legal rights, along with the facility’s rules. Legal rights must be explained in a language they can understand. Residents must be given contact information for state agencies relating to quality of care, such as the ombuds-man program (more information may be found later in the chapter). When requested, survey results must be shared with residents. Residents have the right to be notified about any change of room or roommate. They have the right to com-municate with someone who speaks their lan-guage. They have the right to assistance for any sensory impairment, such as vision loss.
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The right to participate in their own care: Resi-dents have the right to participate in planning their treatment, care, and discharge. Residents have the right to see and sign their care plans after all significant changes. Residents have the right to be informed of risks and benefits of care and treatment, including treatment options and alternatives, and to choose the options they prefer. They have the right to request, refuse, and/or discontinue treatment and care. They can refuse restraints and refuse to participate in ex-perimental research.
Residents have the right to be told of changes in their condition. They have the right to review their medical record. They have the right to choose and change their care providers at any time.
Informed consent is a concept that is part of participating in one’s own care. A person has the legal and ethical right to direct what happens to his or her body. Doctors also have an ethical duty to involve the person in his or her health care. Informed consent is the process by which a person, with the help of a doctor, makes in-formed decisions about his or her health care.
The right to make independent choices: Resi-dents can make choices about their doctors, care, and treatments. They can make personal deci-sions, such as what to wear and how to spend their time. They can join in community activi-ties, both inside and outside the care facility. They have the right to a reasonable accommoda-tion of their needs and preferences. They have a right to participate in resident or family groups, such as a Resident Council. A Resident Council is a group of residents who meet regularly to discuss issues related to the long-term care facil-ity. This council gives residents a voice in facility operations and an opportunity to provide sug-gestions on improving the quality of care.
The right to privacy and confidentiality: Resi-dents have the right to speak privately with anyone, the right to privacy during care, and the right to confidentiality regarding every aspect of
their lives (Fig. 1-12). Their medical, personal, and financial information cannot be shared with anyone but the care team.
Fig. 1-12. Residents have the right to privacy, which in-cludes private communication with anyone. They have the right to send and receive mail that is unopened.
The right to dignity, respect, and freedom: Resi-dents must be respected and treated with dignity by caregivers. Residents must not be abused, mistreated, or neglected in any way.
The right to security of possessions: Residents’ personal possessions must be safe at all times. Facilities must make an effort to protect resi-dents’ property from loss or theft. Possessions cannot be taken or used by anyone without a resident’s permission. Residents have the right to manage their own finances or choose some-one else to do it for them. Residents can request that the facility handle their money. If the care facility handles residents’ financial affairs, resi-dents must have access to their accounts and fi-nancial records, and they must receive quarterly statements, among other things. Residents have the right to not be charged for any care that is covered by Medicaid or Medicare.
Rights during transfers and discharges: Resi-dents have the right to be informed of and to consent to any location changes. Residents have the right to stay in a facility unless a transfer or discharge is needed. Residents can be moved from the facility due to safety reasons (their safety or others’ safety), if their health has improved or worsened, or if payment for
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care has not been received for a determined period of time.
The facility must develop an effective discharge plan for residents that involves each resident’s goals and preferences. This plan must be regu-larly reviewed and updated as appropriate. If the resident is planning to stay at the facility long term, discharge planning still needs to occur, keeping the resident’s preferences in mind.
The right to complain: Residents have the right to make complaints and voice grievances without fear for their safety or care. Facilities must work quickly to address their concerns.
The right to visits: Residents have the right to visits from doctors, family members (including spouses and domestic partners), friends, om-budsmen, clergy members, legal representatives, or any other person. Visits cannot be restricted, limited, or denied on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
Rights with regard to social services: The facil-ity must provide residents with access to social services. This includes counseling, assistance in solving problems with others, and help contact-ing legal and financial professionals.
Guidelines: Protecting Residents’ Rights
G Never abuse a resident physically, emotion-ally, verbally, or sexually. Watch for and imme-diately report any signs of abuse or neglect.
G Call the resident by the name he or she prefers.
G Involve residents in planning. Allow residents to make as many choices as possible about when, where, and how care is performed.
G Always explain a procedure to a resident before performing it.
G Do not unnecessarily expose a resident while giving care.
G Respect a resident’s refusal of care. Residents have a legal right to refuse treatment and care. However, report the refusal to the nurse immediately.
G Tell the nurse if a resident has questions, concerns, or complaints about treatment or the goals of care.
G Be truthful when documenting care.
G Do not talk or gossip about residents. Keep all resident information confidential.
G Knock and ask for permission before entering a resident’s room (Fig. 1-13).
Fig. 1-13. Always respect residents’ privacy. Knock before entering their rooms, even if the door is open.
G Do not accept gifts or money from residents.
G Do not open a resident’s mail or look through his belongings.
G Respect residents’ personal possessions. Handle them gently and carefully. Keep per-sonal items labeled and stored according to facility policy.
G Report observations about a resident’s condi-tion or care.
G Help resolve disputes by reporting them to the nurse.
Residents’ Rights
Maintaining BoundariesIn professional relationships, boundaries must be set. Boundaries are the limits to or within relation-ships. Nursing assistants are guided by ethics
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and laws that set limits for their relationships with residents. These boundaries help support a healthy resident-staff relationship. Working closely with resi-dents on a regular basis may make it more difficult to honor the boundaries of professional relation-ships. Residents may feel that NAs are their friends. If a staff member and resident become personally involved with each other, it becomes more difficult to enforce rules. The resident may expect the NA to break the rules because she thinks they are friends. Emotional attachments to residents are unprofes-sional and may weaken an NA’s judgment. NAs should be friendly, warm, and caring with residents. But they should behave professionally and stay within the limits of set boundaries. Facility rules and the care plan’s instructions should be followed. They are in place for everyone’s protection.
A very important part of protecting residents’ rights is preventing abuse and neglect. Abuse is purposeful mistreatment that causes physical, mental, or emotional pain or injury to someone. There are many forms of abuse, including the following:
• Physical abuse is any treatment, intentional or not, that causes harm to a person’s body. This includes slapping, bruising, cutting, burning, physically restraining, pushing, shoving, or even rough handling.
• Psychological abuse is emotional harm caused by threatening, scaring, humiliating, intimidating, isolating, or insulting a person, or by treating him or her as a child.
• Verbal abuse is the use of spoken or written words, pictures, or gestures that threaten, embarrass, or insult a person.
• Sexual abuse is the forcing of a person to perform or participate in sexual acts against his or her will. This includes unwanted touching or exposing oneself to a person. It also includes sharing pornographic material.
• Financial abuse is the improper or illegal use of a person’s money, possessions, prop-erty, or other assets.
• Assault is a threat to harm a person, result-ing in the person feeling fearful that he or she will be harmed. Telling a resident that she will be slapped if she does not stop yell-ing is an example of assault.
• Battery is the intentional touching of a per-son without his or her consent. An example is an NA hitting or pushing a resident. This is also considered physical abuse. Forcing a resident to eat a meal is another example of battery.
• Domestic violence is abuse by spouses, intimate partners, or family members. It can be physical, sexual, or emotional. The vic-tim can be a man or woman of any age or a child.
• False imprisonment is unlawful restraint that affects a person’s freedom of movement. Both the threat of being physically restrained and actually being physically restrained are types of false imprisonment. Not allowing a resident to leave the facility is also consid-ered false imprisonment.
• Involuntary seclusion is the separation of a person from others against the person’s will. An example is an NA confining a resident to his room.
• Workplace violence is abuse of staff by other staff members, residents, or visitors. It can be verbal, physical, or sexual. This includes improper touching and discussion about sexual subjects.
• Sexual harassment is any unwelcome sexual advance or behavior that creates an intimidating, hostile, or offensive working environment. Requests for sexual favors, un-wanted touching, and other acts of a sexual nature are examples of sexual harassment.
• Substance abuse is the repeated use of legal or illegal drugs, cigarettes, or alcohol in a way that harms oneself or others. For the NA, substance abuse can lead to unsafe
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practices that result in negligence, malprac-tice, neglect, and abuse. It can also lead to the loss of the NA’s certification.
Neglect is the failure to provide needed care that results in physical, mental, or emotional harm to a person. Neglect can be put into two categories: active neglect and passive neglect. Active neglect is the purposeful failure to pro-vide needed care, resulting in harm to a person. Passive neglect is the unintentional failure to provide needed care, resulting in physical, men-tal, or emotional harm to a person. The care-giver may not know how to properly care for the resident, or may not understand the resident’s needs.
Negligence means actions, or the failure to act or provide the proper care for a resident, result-ing in unintended injury. An example of neg-ligence is an NA forgetting to lock a resident’s wheelchair before transferring her. The resident falls and is injured. Malpractice occurs when a person is injured due to professional miscon-duct through negligence, carelessness, or lack of skill.
Nursing assistants must never abuse residents in any way. They must also try to protect resi-dents from others who abuse them. If an NA ever sees or suspects that another caregiver, family member, or resident is abusing a resident, she must report this immediately to the nurse in charge. Reporting abuse or suspected abuse is not an option—it is the law.
Observing and Reporting: Abuse and Neglect
The following injuries are considered suspicious and should be reported:
Poisoning or traumatic injury
Teeth marks
Belt buckle or strap marks
Bruises, contusions, or welts
Scars
Fractures or dislocations
Burns of unusual shape and in unusual loca-tions, or cigarette burns
Scalding burns
Scratches or puncture wounds
Scalp tenderness or patches of missing hair
Swelling in the face, broken teeth, or nasal discharge
Bruises, bleeding, or discharge from the vaginal area
These signs could indicate abuse:
Yelling obscenities
Fear, apprehension, or fear of being alone
Poor self-control
Constant pain
Threatening to hurt others
Withdrawal or apathy (Fig. 1-14)
Fig. 1-14. Withdrawing from others is an important change to report.
Alcohol or drug abuse
Agitation, anxiety, or signs of stress
Low self-esteem
Mood changes, confusion, or disorientation
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Private conversations are not allowed, or the family member/caregiver is present during all conversations
Reports of questionable care by the resident or her family
These signs could indicate neglect:
Pressure injuries
Unclean body
Body lice
Unanswered call lights
Soiled bedding or incontinence briefs not being changed
Poorly-fitting clothing
Unmet needs relating to hearing aids, eye-glasses, etc.
Weight loss or poor appetite
Uneaten food
Dehydration
Fresh water or beverages not being offered regularly
Reports of not receiving prescribed medica-tion by the resident or her family
Nursing assistants are in an excellent position to observe and report abuse or neglect. NAs have an ethical and legal responsibility to observe for signs of abuse and to report suspected cases to the proper person. NAs must follow the chain of command when reporting abuse. If action is not taken, the NA should keep reporting up the chain of command until action is taken. If no ac-tion is taken at the facility level, she can call the state abuse hotline or contact the proper state agency. Abuse can be reported anonymously. If a life-or-death situation is witnessed, the NA should remove the resident to a safe place if pos-sible. The NA should get help immediately or have someone go for help. The resident should not be left alone.
If abuse is suspected or observed, the NA should give the nurse as much information as pos-sible. If a resident wants to make a complaint of abuse, the NA must help her in every way. This includes telling the resident about the process and her rights. NAs must never retaliate against (punish) residents complaining of abuse. If an NA sees someone being cruel or abusive to a resident who made a complaint, she must report it. All care team members are responsible for residents’ safety and should take this responsi-bility seriously.
In long-term care facilities in the United States, an ombudsman is assigned by law as the legal advocate for residents (ltcombudsman.org). The Older Americans Act (OAA) is a federal law that requires all states to have an ombudsman program. An ombudsman visits facilities and listens to residents. He or she decides what ac-tion to take if there are problems. Ombudsmen can help resolve conflicts and settle disputes concerning residents’ health, safety, welfare, and rights. The ombudsman will gather information and try to resolve the problem on the resident’s behalf and may suggest ways to solve the prob-lem. Ombudsmen provide an ongoing presence in long-term care facilities. They monitor care and conditions (Fig. 1-15).
Fig. 1-15. An ombudsman is a legal advocate for residents. He or she visits the facility and listens to residents, and may work with other agencies to resolve complaints.
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To respect confidentiality means to keep pri-vate things private. Nursing assistants will learn confidential (private) information about resi-dents. They may learn about a resident’s health, finances, and relationships. Ethically and legally, they must protect this information. NAs should not share information about residents with any-one other than the care team.
Congress passed the Health Insurance Porta-bility and Accountability Act (HIPAA) (hhs.gov/hipaa) in 1996. It has been further de-fined and revised since then. One reason this law was passed is to help keep health informa-tion private and secure. All healthcare organiza-tions must take special steps to protect health information. Their employees can be fined and/or imprisoned if they do not follow rules to pro-tect patient privacy.
Under this law, a person’s health information must be kept private. Protected health infor-mation (PHI) is information that can be used to identify a person and relates to the patient’s con-dition, any health care that the person has had, and payment for that health care. Examples of PHI include a person’s name, address, telephone number, social security number, email address, and medical record number. Only people who must have information to provide care or to process records should know a person’s private health information. They must protect the infor-mation. It must not become known or used by anyone else. It must be kept confidential.
HIPAA applies to all healthcare providers, in-cluding doctors, nurses, nursing assistants, and any other care team members. NAs cannot give out any information about a resident to anyone who is not directly involved in the resident’s care unless the resident gives official consent or unless the law requires it. For example, if a neighbor asks an NA how a resident is doing, she should reply, “I’m sorry, but I cannot share that information. It’s confidential.” That is the correct response to anyone who does not have a legal reason to know about the resident.
Guidelines: Protecting Privacy
G Make sure you are in a private area when you listen to or read your messages.
G Know with whom you are speaking on the phone. If you are not sure, get a name and number. Call back after you find out it is all right to share information with this person.
G Do not talk about residents in public (Fig. 1-16). Public areas include elevators, gro-cery stores, lounges, waiting rooms, parking garages, schools, restaurants, etc.
Fig. 1-16. NAs should not discuss any information about residents in public places.
G Use confidential rooms for reports to other care team members.
G If you see a resident’s family member or a former resident in public, be careful with your greeting. He or she may not want others to know about the family member or that he or she has been a resident.
G Do not bring family or friends to the facility to meet residents.
G Make sure nobody can see protected health or personal information on your computer screen while you are working. Log out and/or exit the browser when finished with any com-puter work.
G Do not give confidential information in emails. You do not know who has access to your messages.
G Do not share resident information, photos, or videos on any social networking site, such as Facebook, Twitter, Instagram, or Pinterest.
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G Make sure fax numbers are correct before faxing information. Use a cover sheet with a confidentiality statement.
G Do not leave documents where others may see them.
G Store, file, or shred documents according to facility policy. If you find documents with a resident’s information, give them to the nurse.
All healthcare workers must follow HIPAA regu-lations no matter where they are or what they are doing. There are serious penalties for violating these rules, including the following:
• Fines ranging from $100 to $1.5 million
• Prison sentences of up to ten years
Maintaining confidentiality is a legal and ethical obligation. It is part of respecting residents and their rights. Discussing a resident’s care or per-sonal affairs with anyone other than members of the care team violates the law.
8. Explain legal aspects of the resident’s medical record
The resident’s medical record or chart is a legal document. What is documented in the chart is considered in court to be what actually happened. In general, if something does not appear in a resident’s chart, it did not legally happen. Failing to document care could cause very serious legal problems for NAs and their employers. It could also harm residents. NAs must remember that if it was not documented, it was not done. Careful charting is important for these reasons:
• It is the only way to guarantee clear and complete communication among all the members of the care team.
• Documentation is a legal record of every part of a resident’s treatment. Medical charts can be used in court as legal evidence.
• Documentation helps protect nursing as-sistants and their employers from liability
by proving what they did when caring for residents.
• Documentation gives an up-to-date record of the status and care of each resident.
Guidelines: Careful Documentation
G Document care immediately after it is given. This makes details easier to remember. Do not record any care before it has been done.
G Think about what you want to say before docu-menting. Be as brief and as clear as possible.
G Use facts, not opinions.
G Use black ink when documenting by hand. Write as neatly as you can.
G If you make a mistake, draw one line through it. Write the correct information. Put your initials and the date (Fig. 1-17). Do not erase what you have written. Do not use correction fluid. Documentation done on a computer is time-stamped; it can only be changed by entering another notation.
Fig. 1-17. One example of how to correct a mistake.
G Sign your full name and title (for example, Sara Martinez, NA). Write the correct date.
G Document as specified in the care plan. Documentation may be done by code. For example, when documenting activities of daily living (ADLs) on a flow sheet, you may need to choose a code to explain what the resident was able to do. Zero may be classi-fied as independent, 1 as needs supervision, 2 as needs limited assistance, 3 as needs extensive assistance, and 4 as total depen-dence. You will be trained to document prop-erly at your facility.
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G Documentation may need to be done using the 24-hour clock, or military time (Fig. 1-18). Regular time uses the numbers 1 to 12 to show each of the 24 hours in a day. In military time, the hours are numbered from 00 to 23. Midnight is expressed as 0000 (or 2400), 1:00 a.m. is 0100, 1:00 p.m. is 1300, and so on.
1200
1800
12
6
11
7
1
5
2
4
10
8
9 3
0000 or
2400
0600
0100
1300
1700
2300
1900
2200
2000
2100 1500
1400
1600
1100
05000700
02001000
04000800
03000900
PM
AM
Fig. 1-18. Divisions in the 24-hour clock.
Both regular and military time list minutes and seconds the same way. The minutes and seconds do not change when converting from regular to military time. The abbreviations a.m. and p.m. are used in regular time to show what time of day it is. However, these are not used in military time, since specific numbers show each hour of the day. For example, to change 4:22 p.m. to military time, add 4 + 12. The minutes do not change. The time is expressed as 1622 (sixteen twenty-two) hours.
To change the hours between 1:00 p.m. to 11:59 p.m. to military time, add 12 to the regular time. For example, to change 3:00 p.m. to military time, add 3 + 12. The time is expressed as 1500 (fifteen hundred) hours.
Midnight is the only time that differs. It can be written as 0000, or it can be written as 2400. This follows the rule of adding 12 to
the regular time. Follow facility policy on how to express midnight.
To change from military time to regular time, subtract 12. The minutes do not change. For example, to change 2200 hours to standard time, subtract 12 from 22. The answer is 10:00 p.m.
G At some facilities, computers or tablets are used for documentation. Computers record and store information that can be retrieved when needed. This is faster and more accu-rate than writing information by hand. A computer may remain in a resident’s room for care team members to input information each time they visit the room. A computer may be in the hallway or other common area. A computer or tablet may also be carried from room to room. Some general guidelines for computer documentation are listed below:
• If your facility uses computers for docu-mentation, you will be trained to use them. Always ask questions if you do not know or understand something. Some facilities use both handwritten and elec-tronic records. Even when facilities require electronic/computer documentation, training often includes how to document by hand in case there is a system failure.
• Legal documentation rules apply to both electronic and paper medical charts.
• HIPAA privacy guidelines apply to elec-tronic documentation. Make sure nobody can see protected health information on your computer screen. Do not share your log-in information with anyone.
• Do not have someone else enter informa-tion for you, even if it is more convenient.
• Make sure you are logged in to the correct resident’s chart before beginning to docu-ment. Log out and/or exit a resident’s chart when finished with documentation.
• Some computer software automatically fills in certain fields with information that has
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been entered before (autofill). Be sure that you are documenting correctly and that any autofill entries are accurate. Check your entries before exiting a resident’s chart.
• Treat computers carefully.
• Do not use the facility’s computers or tablets to browse the internet or access any personal accounts.
9. Explain the Minimum Data Set (MDS)
The federal government developed a resident assessment system in 1990 and has revised it periodically. It is called the Minimum Data Set (MDS). The MDS is a detailed form with guide-lines for assessing residents. It also lists what to do if resident problems are identified. Nurses must complete the MDS for each resident within 14 days of admission and again each year. In addition, the MDS for each resident must be reviewed every three months. A new MDS must be done when there is any major change in the resident’s condition. NAs contribute to the MDS by reporting changes in residents promptly and documenting accurately. Doing this means a new MDS can be completed when needed.
10. Discuss incident reports
An incident is an accident, problem, or un-expected event during the course of care. It is something that is not part of the normal routine. A mistake in care, such as feeding a resident from the wrong meal tray, is an incident. A resi-dent fall or injury is another type of incident. Accusations made by residents against staff, as well as employee injuries, are other types of in-cidents. State and federal guidelines require that incidents be recorded in an incident report. An incident report (also called an occurrence, acci-dent, accident/incident, or event report) is a report that documents the incident and the response to it. The information in an incident report is con-fidential. It is intended for internal use to help
prevent future incidents. Incident reports should be filed when any of the following occur:
• A resident falls (all falls must be reported, even if the resident says he or she is fine)
• An NA or a resident breaks or damages something
• An NA makes a mistake in care
• A resident or a family member makes a re-quest that is outside the NA’s scope of practice
• A resident or a family member makes sexual advances or remarks
• Anything happens that makes an NA feel uncomfortable, threatened, or unsafe
• An NA gets injured on the job
• An NA is exposed to blood or body fluids
Reporting and documenting incidents is done to protect everyone involved. This includes the resi-dent, the employer, and the nursing assistant. NAs must report any incident, including job- related injuries, immediately to the charge nurse. When documenting incidents, NAs should complete the report as soon as possible and give it to the charge nurse. This is impor-tant so that details are not forgotten.
If a resident falls and the NA did not see it, he should not document “Mr. G fell.” Instead he should document “Found Mr. G on the f loor” or “Mr. G states that he fell.” NAs should write brief and accurate descriptions of the events as they happened. They should not place blame or liability within the report.
Guidelines: Incident Reporting
G Tell what happened. State the time and the mental and physical condition of the person.
G Describe the person’s reaction to the incident.
G State the facts; do not give opinions.
G Do not document that an incident report was completed on the medical record.
G Describe the action taken to give care.
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